Perspectives of African American Church Leaders in Response to COVID-19 Emergency Preparedness and Risk Communication Efforts Within a Community Engaged Research Partnership: COVID-19 emergency risk communication

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Challenges
The COVID-19 pandemic disproportionately affected communities of color, particularly African-Americans (AAs), exacerbating health disparities. 1Since 78% of AAs report belonging to religious organizations, the Fostering African-American Improvement in Total Health!(FAITH!)Program leveraged a successful, longstanding community-academic partnership in April 2020, [2][3][4][5][6] by providing emergency preparedness (EP) plans and COVID-19 information to AA churches in Rochester and Minneapolis-St.Paul (MSP), MN. 7 This mixed-methods study evaluated the initiative's impact on EP promotion within AA communities during the pandemic; assessing church readiness for future public health emergencies, intervention engagement, dissemination, and satisfaction.

Intervention/Context
From April to May 2020, an 8-week EP risk communication intervention was codeveloped with AA churches in Rochester and MSP (AAs 9.1% and 18.4% of population, respectively).In the intervention areas, an estimated 60% of AAs attend Christian congregations.Employing a community-based participatory research approach and a framework adapted from the Centers for Disease Control and Prevention (CDC) Crisis and Emergency Risk Communication framework, a needs assessment was conducted to understand pandemic-related challenges faced by the AA community.Intervention details have been previously published. 7Based on the needs assessment, a faith-based, COVID-19 EP manual was electronically communicated. 7The manual offered step-by-step guidance for structuring church EP initiatives and establishing EP teams (EPTs).Additionally, a culturally tailored social marketing campaign was launched to communicate inspirational, health, and financial, as well as social support messages.The "FAITH! & COVID-19 Spread the Word!" newsletter, co-developed with community leaders, was sent weekly to congregations via email containing scripture-based information to reinforce messages.

Data Collection
The Mayo Clinic Institutional Review Board approved this study.Following informed consent, AA church leaders participated in individual, 1-hour, semi-structured interviews (June-July 2020) via videoconferencing and telephone using a standardized moderator guide.All interviews were recorded and transcribed.Participants received US $50 cash card for interview completion.Churches also received US $500 monetary incentives to enhance EPTs.

Outcomes
We assessed whether churches had an established EPT and the perceived level of church EP at pre-and post-intervention.Furthermore, the intervention was evaluated on engagement, dissemination, satisfaction, and recommendations/suggestions for sustainability.

Analyses
Participant characteristics were summarized using mean, median, and proportions.Initial themes and categories were compiled using an integrated approach of inductive codes emerging from the data and a priori codes derived from interview questions.Multiple readings were conducted to identify preliminary themes.Quantitative analysis utilized SPSS Statistics Version 25 (IBM Corp., Armonk, NY, USA) and qualitative analysis used QSR NVivo software, v10 (Doncaster, Victoria, Australia).
Table 1 displays church EP and intervention evaluation.Pre-intervention, 73% (n = 11) of the churches had a health ministry, while only 27% (n = 4) had an established EPT.About 40% (n = 4) of church leaders felt their churches were prepared for a health crisis.Post-intervention, 73% (n = 11) had established an EPT (or equivalent structure), and 3 leaders planned future EPTs.All 15 churches reported increased readiness for the ongoing pandemic and future health crises.

Qualitative Results
Thematic analysis of semi-structured interviews yielded 4 themes (Table 2) with no differences by interview mode (videoconferencing vs. telephone).
"Perceived Level of Church EP" indicated pre-intervention unpreparedness for health crises like the pandemic.Improved EP post-intervention was attributed to adherence to recommended standards, enhanced knowledge, technology integration, and better communication strategies."Intervention Engagement/ Dissemination" underscored the EP manual's adaptability and its role in launching EPTs.The majority of church leaders valued the weekly emails, finding them highly informative and relevant in addressing pandemic-related needs.Instead of forwarding the emails, leaders often summarized key points for distribution through church communication channels (e.g., email and websites).
"Intervention Satisfaction" revealed that the FAITH!EP intervention significantly impacted EP via the manual.The manual was praised for its accessibility and cultural appropriateness, although some participants cited time constraints and pandemic-related demands as hindrances to fully reviewing and implementing its contents.
The "Intervention Sustainability" theme featured church leaders' recommendations for long-term impact.They proposed sustaining the intervention by including community health needs (e.g., cancer screening), expanding prevention efforts (e.g., distributing hand sanitizers), incorporating non-COVID-19 healthy lifestyle information, and converting the manual into webinars for increased accessibility.

Discussion
This community-centric intervention improved EP in AA churches by establishing new, and enhancing existing EPTs for health crises, including infectious disease outbreaks.The COVID-19 EP manual aided crisis mitigation efforts led by the EPTs.Participants found the intervention messaging reliable and useful.Similar initiatives addressed vulnerable communities' needs elsewhere in the US but lacked an EP focus. 8,9This study underscores the need for immediately deployable, sustainable EP tools (e.g., the FAITH!EP intervention) for church leaders to effectively navigate disasters and keep parishioners safe.
The small sample size and localized geographic region limits generalizability of findings beyond these communities.Nevertheless, we achieved interview saturation, underscoring the validity of the findings and offering valuable insights for enhancing EP in underresourced AA communities.Effective information communication is crucial in the digital transformation era.Participants recommended concise formats, leading to a FAITH! program webinar series covering EP essentials.This highlighted the need for user-friendly digital toolkits in future interventions.Importantly, contextualizing EP strategies is crucial, particularly in socioeconomically disadvantaged communities where unmet or neglected needs are prevalent. 10

Conclusion
Equipping churches equitably with EP resources and tailoring resources through EP assessment are pivotal for effective crisis response in AA communities.

Illustrative quotes
Perceived level of emergency preparedness for a health crisis before and after the intervention "I'd say adequately.I think we've, you know, we've kind of found a system that fits our bandwidth for where we are right now." "… we established different safety protocols for the food shelf.""We had to work with other organizations, bigger food shelves, and the state department, just to make sure we were complying and doing things in a way that was safer."[Female, 48 years] Intervention engagement and dissemination "Very helpful in setting up our own team and coming up with guidelines for reopening.Especially precautionary guidelines.Now of course, the purpose of the resource is for us to set up our own team, which we did, when the church reopened.It was a good resource for us."[Male, 53 years] "How to organize and set up the [emergency preparedness] plan and how to safely implement the plan: that information came straight from the faith-based details they were sending out."[Female, 53] "Based on the written guidelines, someone who didn't have any administration background could use the tool that they had in place." 'It was very, very helpful.Because … it was information.We didn't have to be looking around, sourcing for this information."[Female, 53]   Intervention satisfaction "They [weekly emails/ messaging] are, in terms of content and medical information, both spiritual and informative.Some resources are also economical.Hence, it has balanced content."[Male, 53] "[The information is] coming from a personal perspective; it's coming from a project that we're participating in so there's a relationship.All of it is helpful.We trust [the investigator], and we're trusting Mayo." [Female, 73] "I would say because the information is coming from Mayo and most people know the reputation of Mayo, I think that people are more inclined to engage in the links more than if it was coming from somewhere else.Knowing the work that Mayo is doing and has done, and its' reputation, I think people will engage in it more readily." [Female, 60] "It's always helpful for me, and the information is always enlightening.If people needed resources there are so many updates, and encouragement for people to share their own resources.Hence, for some of the updates, even if I don't listen to the Governor, I see the

COVID-19 healthy lifestyle information "
For this particular program, for FAITH! at first, it was healthy heart care and cholesterol and that kind of stuff.That's because the program appealed to us, because we were just starting a fitness program and it would go hand-in-hand with being mindful of better eating and workout habits."[Female,48]"Resourcesfor the church, and information/ news we don't know, for example, if they're doing antibody testing or something that is not as well known, innovations from other churches, etc. should be included.Something that would give us ideas on how better to connect during this time when it's harder to connect.If the newsletters could have more value, and go a little deeper in the information presented (e.g., safe activities to do outside in nicer weather while maintaining social distancing such as tennis, biking, etc.).I would definitely share such helpful tips more."[Female,48]

Increase overall prevention efforts "
I would add that one of the things that I thought before the pandemic and one of the absolute needs in the African American community, specifically, is how to live a healthy lifestyle.Healthy eating, access to healthcare, dental care, etc.You know, people don't really understand how your teeth are tied to your health.Information Disaster Med Public Health Prep.Author manuscript; available in PMC 2024 April 15.such as having mammograms, cancer screenings, etc., should also be incorporated.Taking some of the stigma and fear from some of the tests, I think would be very, very helpful because some folks don't go to the doctor because they are scared."[Male,58]

Incorporate health needs prevalent in the community "
We all pray COVID will pass, but diabetes, lupus, and heart disease, amongst others are still going to be here."[Male,58]

Ensure messages reach appropriate audiences "
I don't know if there was another way other than Facebook; a lot of our seniors don't use Facebook and would probably would benefit a lot more than our younger members.I know that we're in this age of technology and it's wonderful, but it also leaves out some individuals that also need that information.They're not in tune with new-age learning technology."[Female, 60] "It would be great if someone could actually hold a webinar [on emergency preparedness manual].So you don't have to be reading all the lines, and can just at your convenience, just view instead of reading."[Male, 53]